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ATI RN · ATI Fundamentals · NCLEX Questions Skin Integrity and Wound Care

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?

A. A patient with a clean Stage I

B. A patient with a clean Stage II

C. A patient with a clean Stage III

D. A patient with a clean Stage IV

Expert Explanatory Rationale

Correct Answer: A patient with a clean Stage I

Question 2 of 5

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first?

A. Administer the prescribed morphine 4 mg IV.

B. Contact the operating room to schedule surgery.

C. Check the patient's O2 saturation using pulse oximetry.

D. Ask the patient about the date of the last tetanus immunization.

Expert Explanatory Rationale

Correct Answer: Check the patient's O2 saturation using pulse oximetry.

Question 3 of 5

Which of the following parameters is not considered part of a routine skin assessment?

A. color

B. turgor

C. temperature

D. ankle-brachial index

Expert Explanatory Rationale

Correct Answer: ankle-brachial index

Question 4 of 5

A nurse is caring for a client with septicemia. What assessment by the nurse best addresses the potential for ineffective peripheral perfusion?

A. Monitor heart rate every hour.

B. Assess temperature every 4 hours.

C. Monitor pupil reactions every 8 hours.

D. Monitor for cyanosis.

Expert Explanatory Rationale

Correct Answer: Monitor for cyanosis.

Question 5 of 5

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures?

A. Tack down scatter rugs in the home.

B. Expect most falls to happen outside the home.

C. Buy shoes that provide good support and are comfortable to wear.

D. Get instruction in range-of-motion exercises from a physical therapist.

Expert Explanatory Rationale

Correct Answer: Buy shoes that provide good support and are comfortable to wear.

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